Subjective
- Biographical Data:
- Name: Mr. Smith.
- Age: 70yrs.
- Race: British Male.
- Marital Status: Married.
- General Appearance:
- Fair general condition.
- Source/Reliability:
- Retired from the local university where he was the supervisor of the Building & Grounds department.
- Chief Complaint (CC):
- Increased frequency in urination.
- Incomplete bladder emptying.
- Hard time starting a stream of urine.
History of Present Illness (HPI)
Mr. Smith, a 70-year-old British male, arrives with symptoms of difficulties initiating urine and dribble following urination. He claims he noticed this a month ago but did not consider it serious, until the situation became difficult for him. He reports having frequent urges to urinate, particularly at night. According to him, urine is a feeble stream that frequently stops and begins; it is never continuous. He explains that on many days, he was unable to entirely pass the pee and has a continuous sensation of leftover urine regardless of the frequency of urination. He denies having any reproductive system disorder and maintains that he was not involved in any accident that may have harmed his reproductive system. His prior medical history is noteworthy for type 2 diabetes mellitus, which is effectively managed with Metformin XL 500 mg twice a day. He walks almost a mile each evening, is an active member of his church and maintains gardens. He “piddles” around his business and yard and lives nearby with his 50-year-old wife and their children. He just retired from a nearby university where he served as the supervisor of the Building and Grounds department. His symptoms began a few months ago but are now significantly impairing his quality of life and interfering with his sleep. He denies having a urinary tract infection and there is no history of experiencing a burning sensation when urinating. He maintains that he has not seen any fast weight gain and that he exercises on a daily basis. He explains to have no family history of prostate cancer or any other issue relating to the prostate.
History (Hx)
- Health Insurance/Status; Pharmacy Coverage:
- PMH (Medical Hx): Known Type 2 DM
- PSHx (Surgical Hx): N/A
- FHx (Family Hx): patient denies positive family history of hypertension, cardiovascular disease including stroke, genetic disorders including cancer.
- SHx (Social Hx): He lives with his wife of 50 years, and their children live nearby.
- Health Maintenance: He walks about a mile each evening, is active in his church, gardens. and also “piddles” in his shop and yard.
- Allergies: N/A
- Current meds: Metformin XL 500 mg qd
- Review of Systems (ROS): ROS is negative for all systems except for the urinary system. The associated symptoms are of frequent urination, feeling like he is unable to completely empty his bladder, and having a hard time starting a stream of urine.
Objective
- Vital Signs:
- BP: 110/70mmHg
- HR: 62
- RR: 16
- Weight: 72kgs
- Height: 67 inch
- Physical Examination:
- General: Well-groomed, well-nourished with no signs of distress in fair general condition.
- PE: Digital rectal exam demonstrates a big (50 g) soft, symmetric, non-tender prostate without nodules or regions of induration with normal external genitalia. There is no tenderness in the costovertebral region and there is no rectal pathology.
- Diagnostics/Procedures:
- Digital Rectal Exam: The prostate gland is palpable, large in size, soft, symmetric, non-tender with no palpable nodules and no regions of induration. According to the patient, there was discomfort when the prostate gland was palpated.
- Trans-rectal ultrasound – it was discovered that the prostate gland had grown in size around the perimeter.
Assessment
Benign Prostatic Hyperplasia (N42.3) is a condition that affects the prostate gland. It is a histologic diagnostic that is defined by the proliferation of prostate cells on the histological specimen under examination. It is a benign development of the prostate that develops in the peri-ureteral and transition zones of the urinary tract (Langan, 2019). As a result, BPH is neither malignant, infectious, or spread through sexual contact. The urethra is squeezed as the prostate gland expands, and the muscles surrounding the urethra constrict when the prostate gland contracts. This causes symptoms such as difficulties urinating, increased urgency and frequency of urine, incontinence, and increased resistance during urination to manifest themselves and is particularly prevalent among senior men (Langan, 2019). Chronic bladder outlet blockage caused by BPH can result in urine retention, recurrent urinary tract infections (UTI), renal insufficiency, hematuria, and bladder calculi. In this case, the symptoms that the patient exhibited were consistent with the diagnosis.
Differential Diagnosis
Urethral Stricture (N35)
The symptoms of obstructive voiding (such as reduced stream force, incomplete emptying, and urine intermittency), urinary tract infection (UTI), and urinary retention are all possible outcomes. The establishment of efficient bladder drainage is often a hard endeavor. It can occur as a result of inflammation, ischemia, or trauma. These mechanisms cause scarring of the tissue development, which results in increased resistance to ante grade urine flow (Madersbacher et al., 2019). Based on the physical examination that was performed as well as the laboratory testing, this condition was ruled out.
Overactive Bladder (N39.3)
It is possible to characterize this situation as the sudden and urgent need to urinate. Asymptomatic urine urgency, which can be accompanied with or without urinary incontinence, is the hallmark of this condition (Lokeshwar et al., 2019). When there are no metabolic abnormalities present, it is frequently linked with frequency and nocturia. Weak muscles, nerve damage, drug usage, alcohol or caffeine consumption, illness, and being overweight can all be contributing factors and changes in one’s way of life may be beneficial.
Acute Bacterial Prostatitis (N41.0)
A rise in the number of inflammatory cells in the prostate gland as a result of an infection can be defined as follows as an acute urinary tract infection (UTI) is the presenting symptom. It is related to variables, such as bladder outlet blockage. This causes BPH urinary tract symptoms such as dysuria, urinary frequency, and urinary retention are caused by an acute bacterial prostatitis infection of the prostate gland. These may also produce fevers, chills, nausea, emesis, and malaise, in addition to the aforementioned pelvic pain and urinary tract symptoms.
Prostate Cancer (D29.1)
There may be some signs, such as difficulties urinating, but in some cases, there are no symptoms at all. Some forms of prostate cancer progress more slowly than others. A monitoring program is recommended in several of these situations (Lokeshwar et al., 2019). Other kinds are more aggressive and need the use of radiation, surgery, hormone therapy, chemotherapy, or other therapies to control their spread.
Carcinoma of the bladder (N39)
Bladder cancer occurs when an abnormal development of bladder lining tissue, referred to as a tumor, develops. When a tumor grows much further, it might invade the bladder muscle. The signs and symptoms include blood in the urine (hematuria) causes the urine to look bright red or cola-colored. In other cases, the urine appears normal and blood is discovered on a laboratory test (Lokeshwar et al., 2019). Urination on a regular basis is associated with excruciating pain.
Plan and Treatment
A range of surgical options are available for the treatment of BPH patients. In the treatment of bladder obstruction caused by benign prostatic hyperplasia, transurethral resection of the prostate is performed. Patients with a prostate that weighs more than 75 grams and who also have bladder stones are candidates for open prostatectomy (Foster et al., 2018). Patients who are unable to be positioned for transurethral surgery may potentially benefit from this procedure.
Medications
- Continue Metformin XL 500 mg qd.
- Tadalafil 5mg PO OD.
- Finasteride 5mg PO OD.
- Doxazosin 1mg PO OD.
Lab Tests
- Prostate-specific antigen (PSA) to determine PSA levels that are likely to be elevated in prostate cancer.
- Urinalysis both microscopic, macroscopic, and dipstick to determine the presence of pus cells and proteins in urine indicative of urinary tract infection.
- Urea, electrolytes, and creatinine to determine the level of kidney functioning.
- Complete blood count to determine hemoglobin levels and any features of systemic infection.
Health Maintenance
- Avoid foods that exacerbate symptoms such as caffeine and alcohol.
- Clear the bladder once you feel the urge to urinate to avoid.
- Avoid over-the-counter medications such as antihistamines and decongestants.
- Stress management.
- Continue with regular exercise since exercise is indicated in improving symptoms associated with BPH.
- Practice Kegel exercise to strengthen pelvic muscles and keep warm.
Evaluation and Follow-up
Lower urinary tract symptoms (LUTS), poor bladder emptying, urine retention, detrusor instability, urinary tract infection, hematuria, and renal insufficiency are all signs of benign prostatic hyperplasia (BPH). However, LUTS is the sole symptom seen in the majority of men with BPH. Men with LUTS must first be evaluated to determine if they have BPH or not, and if they do, to determine the severity of the problem. Using the American Urological Association Symptom Index or International Prostate Symptom Score, it is critical to gauge the intensity of symptoms both at the start of treatment and during the course of treatment. After that, further specific tests can help limit the diagnosis and direct therapy choices. The management will also be affected by factors such as the age of the patient and the presence of concurrent cancer, but the fundamental objective of treatment remains the enhancement of the patient’s quality of life.
References
Foster, H. E., Barry, M. J., Dahm, P., Gandhi, M. C., Kaplan, S. A., Kohler, T. S., & McVary, K. T. (2018). Surgical management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA guideline. The Journal of Urology, 200(3), 612-619.
Langan, R. C. (2019). Benign prostatic hyperplasia. Primary Care: Clinics in Office Practice, 46(2), 223-232.
Lokeshwar, S. D., Harper, B. T., Webb, E., Jordan, A., Dykes, T. A., Neal Jr, D. E., & Klaassen, Z. (2019). Epidemiology and treatment modalities for the management of benign prostatic hyperplasia. Translational Andrology and Urology, 8(5).
Madersbacher, S., Sampson, N., & Culig, Z. (2019). Pathophysiology of benign prostatic hyperplasia and benign prostatic enlargement: a mini-review. Gerontology, 65(5), 458-464. Web.